Context Behavioural interventions are used to prevent, manage and treat a wide variety of conditions including obesity, diabetes, chronic pain, asthma and emotional difficulties. There has been inadequate attention to the delivery of behavioural interventions to younger children (5–11 years old).
Objective Our objectives were to describe the characteristics of behavioural interventions for children aged 5–11 years.
Data sources We searched five databases: CINAHL, EMBASE, PsycINFO, MEDLINE and Cochrane Library, from January 2005 to August 2019.
Study selection The inclusion criteria were (1) children aged 5–11, (2) cognitive and/or behavioural interventions, (3) randomised controlled trials and (4) 2005 onward. Two researchers independently identified studies for inclusion.
Data extraction Two researchers independently extracted data from eligible papers.
Results The search identified 10 541 papers. We extracted information on 117 interventions (from 152 papers). Many of the interventions were categorised as complex. This was particularly true for clinical populations; 78.7% were delivered to both the child and parent, and 33.9% took place across multiple settings, typically health and school settings. Most (70.9%) were ‘First Wave’ (behavioural) interventions, and few (4.3%) were ‘Third Wave’ (characterised by metacognition, acceptance and mindfulness). Thirty-nine per cent used interactive techniques (play, arts, story and/or games). Purely digital and paper-based interventions were rare, but around a third used these tools as supplements to face–face delivery. There were differences in interventions for younger (5–7 years) and older (8–11 years) children.
Conclusions Interventions designed and delivered to children should be developmentally sensitive. This review highlights characteristics of interventions delivered to children 5–11 years old: the involvement of the child’s parent, using behavioural (rather than cognitive) modalities, using interactive techniques and some interventions were delivered across multiple settings.
- child psychology
- paediatric practice
- comm child health
- general paediatrics
- health service
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What is known about the subject?
Behavioural interventions can be used to prevent, treat and manage a range of health conditions. Children 5–11 years old have distinct physical, emotional, social and cognitive developmental characteristics. These developmental differences should be considered when designing interventions for children.
What this study adds?
This review highlights intervention characteristics to consider when designing and delivering interventions for children 5–11 years old. Interventions for children aged 5–11 years typically involve parents, span multiple settings, use a ‘First Wave’ behavioural modality and integrate interactive techniques (play, arts, story and/or game-based techniques).
Health in childhood lays the foundations for health across the lifespan.1–7 Behavioural interventions are used to prevent, manage and treat a range of health conditions in childhood. Behavioural interventions targeting lifestyle behaviours, such as a healthy eating and physical activity,8 can prevent obesity, dental problems and osteoporosis. Behavioural interventions can support the management of long-term health conditions such as attention deficit hyperactivity disorder (ADHD), asthma, diabetes, chronic pain and cystic fibrosis, by promoting medication adherence, monitoring of health markers (eg, insulin and blood pressure)9 and engagement in condition-specific health behaviours. In some cases, behavioural intervention can be used to treat a condition, as in depression and anxiety, where the treatments tackle the maladaptive cognitions and behaviours that underlie the disorder.10
Behavioural interventions (‘First Wave’) are based on the theory that all behaviours are learnt (through classical and operant conditioning)11 and that maladaptive behaviours can be changed using principles such as reinforcement, modelling, graded tasks and habit formation.12 Cognitive-behavioural (CBT, ‘Second Wave’) interventions are based on the principle that thoughts, feelings, physical sensations and actions are interconnected; individuals are supported to identify negative/unhelpful patterns in their cognitions, emotions, behaviours, physical sensations and supported to adopt more adaptive patterns.13 The ‘Third Wave’ of cognitive-behavioural interventions are characterised by techniques such as metacognition, acceptance, mindfulness, compassion and spirituality.11
While behavioural interventions are commonly used in adolescent populations, less is known about the appropriate or effective ways to deliver interventions in younger, primary-school-aged children (5–11 years). Inadequate attention has been paid to designing/adapting interventions for the specific developmental stage of this age group14 15 and comparatively fewer trials evaluating them in this younger age group.15–17
Theory should be used when developing interventions18–21; when designing interventions for children, this means considering development theory.14 22 ,22 Younger children have distinct physical, emotional, social and cognitive developmental characteristics. Younger children (under seven) are pre-logical and their thinking is dominated by perception. From the age of seven onward, children start to think logically, but until age 12, they are still limited to concrete rather than abstract thought processes.13 In line with cognitive development, children hold more basic beliefs about illness (“When you leave the window open, your blankets get cold which can make you a little bit sick”) and magical thinking about illness.23 Children are more reliant on caregivers. Parents/carers are typically the gatekeepers to recognising their child’s health needs, accessing services and implementing/overseeing health interventions.24 Children are also more reliant on caregivers at school, relying on teachers to support the management of their health condition.25
A better understanding of the characteristics of behavioural interventions for children will be helpful for researchers developing and evaluating interventions, as well as clinicians implementing them. Mapping reviews are useful when synthesising information from a broad field of study, covering a large volume of literature.26 This study aims to ‘map’ behavioural interventions designed for younger primary-school-aged children (5–11 years old) to describe the way they are delivered to this age group in terms of recipients, modality, setting, mode and techniques of delivery.
We carried out a mapping review to answer the question: “how are behavioural interventions delivered to children aged 5–11?”.
The search strategy was developed with a University of Bristol data specialist. It included keywords and MeSH headings for (1) children aged 5–11, (2) cognitive and/or behavioural interventions, (3) randomised controlled trials (RCTs) and (4) 2005 to present (online supplementy appendix A). The search was carried out on relevant databases: CINAHL, EMBASE, PsycINFO, MEDLINE and the Cochrane Library (August 2019).
Titles and abstracts (stage one) and full-text papers (stage two) were double screened against inclusion/exclusion criteria (table 1) using the data management platform Covidence.27 Reasons for exclusion were recorded at stage two. Discrepancies at both stages were discussed and resolved in meetings by reviewers. If the full text did not contain the information needed, we made two attempts to contact authors by email. If information was not provided, the study was excluded.
Data extraction and synthesis
Data were independently extracted by two researchers and conflicts resolved in regular meetings. We extracted characteristics of the population and intervention as described in table 2. We created categories for these based on existing taxonomies/coding systems or through an inductive process.
Quality assessment/risk of bias
We believe that there are no quality assessment tools for mapping review methodology.26 Further, given the large volume of studies in this review, it was not feasible to carry out quality assessment.
Patient and public involvement
We did not involve patients or the public in our work.
The search identified 10 541 papers. In total, 5583 were excluded at the title and abstract review stage, and 1975 were excluded at the full-text review stage. The most common reasons for exclusion at full text were wrong age (n=1070), not an RCT (n=577) and wrong paper type (protocol, abstract, presentation etc; n=206). One hundred and fifty-two papers were eligible for the mapping review. The PRISMA diagram28 is displayed in figure 1.
Of the 152 citations, 21 interventions were described across two or more papers, and eight papers included two different active interventions. Therefore, in total we extracted data from 117 interventions.
Populations: 56 interventions (47.9%) targeted clinical populations; 41 (35.0%) targeted healthy populations; 19 (16.2%) targeted at-risk populations. One intervention was for healthy population, with a more intensive component for a subset of at-risk participants. Figure 2 displays the characteristics of intervention for each population.
Age: 72 interventions (61.5%) included both younger (5–7 years old) and older (8–11 years old) children. Twenty-eight (23.9%) included older children only and 17 (14.5%) included younger children only. Figure 3 displays the characteristics of intervention for these different age groups.
Condition/behaviour: 54 interventions (46.2%) targeted lifestyle behaviours (diet, physical activity, dental care, hand washing, injury prevention, sexual health, substance use); 41 (35.0%) were for social–emotional–behavioural presentations (anxiety, conduct/opposition disorder, trauma, depression, behavioural problems); 14 (12.0%) were for neurodevelopmental disorders (ADHD); 8 (6.8%) were for physical symptom management/treatment (bladder/bowel dysfunction, asthma, cystic fibrosis, pain, sleep disorder).
Recipients: 75 interventions (64.1%) involved parents. Of these, 66 (88%) involved both parent and child, and 9 (12%) were parent only. Considering the younger children (5–7 years old), all interventions for clinical populations included parents. None of the interventions for children 8–11 years old were delivered without the child (figure 3). Fifty-nine interventions (78.7%) for clinical and at-risk populations involved parents.
Six of the RCTs were designed to compare the effectiveness of child versus parent involvement; exploring parents exclusively versus parents and child29–31 or child exclusively versus child and parent.32–34
In some cases, a rationale for including parents was not provided. Where a rationale was provided, this included a theoretical rationale (social cognitive and parenting theories)32 35–37; the role of parents in controlling the child’s social and physical environment38–42; and providing reward and reinforcement,29 30 40 43–45 modelling32 36 39 and a developmental rationale, that is, the child’s limited cognitive capacity.46
Modality: 83 interventions (70.9%) used a ‘First Wave’ behavioural approach,11 51 (43.6%) used ‘Second Wave’ cognitive-behavioural approaches and 5 (4.3%) used a ‘Third Wave’ approach. There were no ‘Third Wave’ interventions for younger children (5–7 years old) (figure 3).
For some of the intervention components, the child was a passive recipient; the components were based on changing the environment around the child to change their behaviour. Twenty-five (21.4%) used environmental restructuring (ie, changing the physical environment to change behaviour) including the provision of healthy foods,37 39 47–50 sports sessions and equipment,37 39 41 51–54 moving a TV out of the child’s bedroom,48 55 provision of fluoride toothpaste56 and offering recreational activities.48 56 57 Examples of structuring the social environment included activities designed to change the ecology of the classroom environment58 and activities changing the school-wide climate.59
Some intervention components required the child to be an active participant in therapy.44 45 59–65 They were required to engage in the intervention through learning psychoeducational material, engaging in self-monitoring, self-regulation and self-management.
Intervention setting: 71 interventions (60.7%) took place within a school setting. Fifty-three (45.3%) took place in a clinical setting and 17 (14.5%) took place in a community setting (including the fire service, police, girl guides/brownies and local gyms/recreation centres). Twenty-seven (23.1%) of all interventions, and 19 (33.9%) of interventions for clinical populations, were delivered across multiple settings.
Mode of delivery: The most common mode of delivery was face–face (n=113, 96.6%), either in a group (n=75), individual setting (n=17), a mixture of both (n=19), or group versus individual delivery as comparator arms in the RCT (n=2). Three were purely digital interventions, and one was delivered via printed material. Fifty-four (50%) included multiple modes of delivery; this included face–face with additional printed material (n=26, 22.2%) or additional digital components (n=14, 12.0%). Eighty-seven (74.4%) used some form of standardisation for the intervention delivery, including treatment protocols, manuals and session plans.
Techniques of delivery: 42 interventions included some form of play, arts, story and/or game-based technique (table 3); this equated to 39.3% of the interventions with a child recipient (ie, excluding those delivered to parents only).
Narratives, storytelling and characters were integrated into CBT programmes, used in behavioural/psychoeducational interventions, and two studies used stories or characters as stand-alone interventions. Forty interventions (34.2%) used reward principles, and many implemented this in the form of a game; children could earn points, prizes, stickers and treats for adhering to the treatment plan. In most interventions, caregivers (parents, teachers) were responsible for structuring the reward system.66–69 Some interventions used quizzes and card games to promote knowledge about health behaviour or health management. This was either as a stand-alone intervention or within a multicomponent intervention. Group activities were used to impart knowledge,40 70–72 teach skills,73 engage,74–76 and encourage interaction between group members.59
Many studies did not provide a rationale for including interactive techniques. In the cases where papers supplied a rationale, they stated that interactive techniques were developmentally appropriate,31 suited the child’s stage of cognitive development,74 77 made concepts concrete,78 provided visual information,77 promoted communication,77 were more engaging,78 were tools for modelling behaviour66 79 and were favourable for children’s learning.74
Complexity: 70 interventions (59.8%) were categorised as complex. The dimensions of complexity are summarised in table 4.
Effect of interventions
Forty-eight papers failed to define a primary outcome, and a further 13 papers did not provide data on effectiveness/efficacy because they were RCT pilot studies, process evaluation studies or other types of paper which did not report effectiveness data. As such, we were able to assess the primary outcome for 56 interventions; of these, 26 interventions led to an improvement on the primary outcome, 23 did not lead to improvement on the primary outcome and 7 had mixed results (there was more than paper reporting on the intervention). Figure 4 displays the results of interventions with a primary outcome, presented by modality (note that an intervention may use more than one modality if it is multicomponent). There were a similar number of effective and non-effective behavioural interventions. We did not identify any effective third-wave interventions.
Summary of findings
This is the first systematic review to map and describe how behavioural interventions are delivered to children aged 5–11. Parental involvement in interventions was common (64.1%). Many of the interventions were categorised as ‘complex’18; they contained several components, included multiple modes of delivery, were delivered to more than one recipient and took place across different settings. This was particularly true for interventions delivered to clinical populations, where the majority were delivered to both the child and parent (78.7%), and around a third (33.9%) took place across multiple settings, typically a healthcare setting and school setting. Most (70.9%) were ‘First Wave’ behavioural interventions, and few (4.3%) were ‘Third Wave’. Many of the interventions integrated interactive techniques. Purely digital and paper-based interventions were rare, but around a third used these tools as supplements to face–face delivery. There were potentially differences in interventions for younger (5–7 years) and older (8–11 years) children; interventions for younger children tended to have more parental involvement (all of the clinical interventions for children aged 5–7 years included parents), did not use ‘Third Wave’ approaches and more commonly used reward/reinforcement techniques. All interventions for older children involved the child as a recipient compared with 82.4% of the interventions for younger children. However, because of the small number of interventions for children 5–7 years old, it is hard to draw firm conclusions.
Strengths and limitations
This review was not restricted to a specific health condition/behaviour. This allowed us to explore the principles of delivering interventions to younger children across a broad spectrum of health conditions/behaviours. We provided the interventions’ modality (First, Second or Third Wave), but because of the size of the review it was not feasible to code specific techniques used in more detail, for example using the Behavioural Change Technique Taxonomy.12
We excluded observational cohort studies for pragmatic reasons; including observational studies to the data set would have made analyses unwieldy. While observational studies may have added some richness to the data, there were sufficient data in the RCTs to answer the research questions. Including only RCTs allowed us to focus on interventions most likely to be adopted into clinical care and those that were reported with higher quality.80 However, there was still wide variation in how interventions were reported, according to level of detail and terminology used. As such, there was a degree of subjectivity in data extraction of elements such as modality (eg, behavioural vs CBT) and standardisation (manualised vs non-manualised treatment). To mitigate this, we carried out independent double extraction, using established coding systems and taxonomies (for modality,11 mode of delivery,81 ages82 and population type83) and developed additional guidance documents.
This study was primarily designed to describe the characteristics of the interventions. We do present some data about the efficacy of these interventions; however, we cannot draw strong interpretations from this as we only reviewed primary outcomes (unavailable for 40% of the studies) and we did not carry out quality assessment.
Implications in context of literature
When designing and delivering interventions for children, they should be developmentally sensitive14 22 22 and rooted in developmental theory. Theory on cognitive development states that children tend to be limited to concrete rather than abstract thought,13 as well as less sophisticated illness beliefs.23 As such, concrete interventions focused on behavioural recommendations are more appropriate.24 Consistent with this, behavioural interventions were most common, though we did find that a similar number of effective and non-effective behavioural interventions. CBT requires logical analysis and abstract thinking, and there are caveats on how this should be used with children.13 We found fewer CBT-based therapies. There were only five third-wave interventions, and none were delivered to children under the age of 7. The limited use of these approaches is consistent with existing literature stating that third-wave approaches may not be appropriate for children,3 and concepts such as metacognition are likely to be beyond the cognitive capacities of this younger population. Alternatively, the low number of papers may be because this is a relatively new approach with children; research is in its early stages but is gaining interest, with examples of RCTs currently underway.4 The papers included in this review suggest it may be possible to adapt third-wave concepts, to make them developmentally appropriate for younger children, using exercises, visuals, characters and drawing to make these abstract concepts more concrete, as well as providing briefer interventions.5 From the few studies in this review, we did not identify any effective third-wave interventions. At this stage, third-wave approaches for children are novel and untested, but worthy of more investigation to evaluate effectiveness, and explore how they can be delivered to children in a developmentally sensitive way.
Interactive methods are suited to the cognitive developmental stage of children 5–11 years old. Children can find it difficult to process abstract information and express themselves verbally.13 84 Art-based methods can provide an opportunity to communicate visually,85 likewise stories can include visual supports and are engaging for children.86 Play is an important part of childhood; it is enjoyable, rewarding, and can support children to learn skills and behaviours.87 Many interventions reviewed here used arts, play and games-based techniques to engage and teach children. Developmental theory also highlights the importance of caregivers; in childhood, caregivers play a key role in structuring the child’s environment and shaping the child’s behaviour.24 88 Children are embedded in the family context. Equally, children may spend many hours a day at school in the care of teachers. In this review, many studies included parents and schools, and parental involvement was greatest for the younger children.
Although many interventions included in this review appeared informed by developmental theories, many did not explicitly report how developmental theory guided intervention design. Intervention development and reporting would be improved by doing so.
In this review, there are many examples of interventions which target the same behaviour/condition for similar populations but have been developed independently. However, guidance for developing interventions recommends using a systematic review to identify existing evidence-based interventions,18 and refining these to investigate optimal delivery, rather than developing a novel one.
This review highlights issues about trial design in this field. A clearly defined and pre-specified primary outcome is important; it reduces the risks of selective reporting of outcomes and false-positive from analysing too many outcomes.6 However, we found that around 40% of the interventions failed to specify a primary outcome.
Tools to aid the design and reporting of interventions do not sufficiently capture characteristics important for delivery to children; the Behaviour Change Techniques Taxonomy12 does not sufficiently cover interactive techniques or delivery via parent proxies. Future work to incorporate these techniques may enhance these tools.
In this mapping review, we identified areas of interest around parental involvement, the use of digital interventions to supplement face–face delivery and setting (delivery in both school and clinics). Future systematic reviews could focus on these areas.
The corresponding author wishes to thank Catherine Borwik (University to Bristol, Information Specialist) for helping develop the search strategy.
Contributors AB conceptualised the study as part of a PhD program, drafted the protocol, created the search strategy, screened papers and carried out data extraction, drafted the manuscript, approved the final manuscript as submitted and agree to be accountable for all aspects of the work. RMP drafted the protocol for the study, screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. CL screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. NH-S screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. RR screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. ML provided supervision of data collection and analysis, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. AD drafted the protocol for the study, provided supervision of data collection and analysis, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. SS screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. LB drafted the protocol for the study, screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. RM drafted the protocol for the study, provided supervision of data collection and analysis, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. SY screened papers and carried out data extraction, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. EC drafted the protocol, created the search strategy, provided supervision of data collection and analysis, critically reviewed the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Funding AB is funded by the National Institute for Health Research (Doctoral Research Fellowship, DRF-2017-10-169). EC is funded by the National Institute for Health Research (Senior Research Fellowship, SRF-2013-06-013).
Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All the data relevant to the study are included in the article or uploaded as supplementary information.